FIMR/HIV Maternal Interview Form

Fetal-Infant Mortality Review: Human Immunodeficiency Virus Prevention Methodology (FHPM)

Documents and Forms

Document Name Document Type
Form 2 FIMR/HIV Maternal Interview Form Form and Instruction
2 Maternal Interview Consent Form Maternal Interview Consent Form.docx Form and Instruction
1 Maternal Interview Form Maternal Interview Form.docx Form and Instruction
Attachment 3.c Maternal Interview Form - Creole.pdf Attachment 3 IC Document
Attachment 3.d Maternal Interview Form - Spanish.pdf Attachment 3 IC Document
Attachment 3.b Maternal Interview Form - French.pdf Attachment 3 IC Document
Attachment 4.d Maternal Interview Consent Form - Spanish.doc Attachment 4 IC Document
Attachment 4.c Maternal Interview Consent Form - Creole.doc Attachment 4 IC Document
Attachment 4.b Maternal Interview Consent Form - French.doc Attachment 4 IC Document

Information Collection (IC) Details

IC Title:	FIMR/HIV Maternal Interview Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Maternal Interview Consent Form	Maternal Interview Consent Form.docx		Yes	No	Fillable Fileable
Form and Instruction	1	Maternal Interview Form	Maternal Interview Form.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 3	Attachment 3.c Maternal Interview Form - Creole.pdf	07/01/2011
Attachment 3	Attachment 3.d Maternal Interview Form - Spanish.pdf	07/01/2011
Attachment 3	Attachment 3.b Maternal Interview Form - French.pdf	07/01/2011
Attachment 4	Attachment 4.d Maternal Interview Consent Form - Spanish.doc	07/01/2011
Attachment 4	Attachment 4.c Maternal Interview Consent Form - Creole.doc	07/01/2011
Attachment 4	Attachment 4.b Maternal Interview Consent Form - French.doc	07/01/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.